Rail Accident Report
Pedestrian struck by a train at Lady Howard
footpath and bridleway crossing, Surrey,
21 April 2022
Report 01/2023
v2 February 2024
This investigation was carried out in accordance with:
• the Railway Safety Directive 2004/49/EC
• the Railways and Transport Safety Act 2003
• the Railways (Accident Investigation and Reporting) Regulations 2005.
© Crown copyright 2024
You may reuse this document/publication (not including departmental or agency logos) free of charge in
any format or medium. You must reuse it accurately and not in a misleading context. The material must
be acknowledged as Crown copyright and you must give the title of the source publication. Where we
have identified any third party copyright material you will need to obtain permission from the copyright
holders concerned. This document/publication is also available at www.gov.uk/raib.
Any enquiries about this publication should be sent to:
RAIB Email: enquiries@raib.gov.uk
The Wharf Telephone: 01332 253300
Stores Road Website: www.gov.uk/raib
Derby UK
DE21 4BA
This report is published by the Rail Accident Investigation Branch, Department for Transport.
Version Date Location of change(s) Description of change
v1.0 14 February 2023 All Initial issue
v2.0 6 February 2024 Summary 3 para
rd
Text added concerning the
possibility of a derogation
Summary 4 para
th
Text describing the learning
point added
Para 7 Description of signals and
their position relative to the
crossing
Para 62 Description of strike in point
added
Para 63 Expansion of the description
of different types of MSL
Paras 64 to 68 New paragraphs on
standards and derogations
Para 69 onwards Renumbered
Para 72 Last sentence changed
Para 73 New paragraph on option
selection report
Para 74 Re-phrased to reflect new
evidence
Para 75 to 79 New paragraphs to reflect
new evidence
Para 80 Tense change in first line
Para 82 Changed to reflect new
evidence
Heading before Para Heading changed
100
Heading before Para New heading
103
Paras 103 to 105 New paragraphs for actions
taken between publication of
original and revised versions
Heading before Para New heading
107
Para 107 New learning point
Footnote 10 New footnote regarding
learning point
Throughout Paragraph numbering and
cross references updated to
reflect extra paragraphs
Preface
Preface
The purpose of a Rail Accident Investigation Branch (RAIB) investigation is to
improve railway safety by preventing future railway accidents or by mitigating their
consequences. It is not the purpose of such an investigation to establish blame or
liability. Accordingly, it is inappropriate that RAIB reports should be used to assign
fault or blame, or determine liability, since neither the investigation nor the reporting
process has been undertaken for that purpose.
RAIB’s findings are based on its own evaluation of the evidence that was available at
the time of the investigation and are intended to explain what happened, and why, in a
fair and unbiased manner.
Where RAIB has described a factor as being linked to cause and the term is
unqualified, this means that RAIB has satisfied itself that the evidence supports both
the presence of the factor and its direct relevance to the causation of the accident or
incident that is being investigated. However, where RAIB is less confident about the
existence of a factor, or its role in the causation of the accident or incident, RAIB will
qualify its findings by use of words such as ‘probable’ or ‘possible’, as appropriate.
Where there is more than one potential explanation RAIB may describe one factor as
being ‘more’ or ‘less’ likely than the other.
In some cases factors are described as ‘underlying’. Such factors are also relevant
to the causation of the accident or incident but are associated with the underlying
management arrangements or organisational issues (such as working culture).
Where necessary, words such as ‘probable’ or ‘possible’ can also be used to qualify
‘underlying factor’.
Use of the word ‘probable’ means that, although it is considered highly likely that the
factor applied, some small element of uncertainty remains. Use of the word ‘possible’
means that, although there is some evidence that supports this factor, there remains a
more significant degree of uncertainty.
An ‘observation’ is a safety issue discovered as part of the investigation that is not
considered to be causal or underlying to the accident or incident being investigated,
but does deserve scrutiny because of a perceived potential for safety learning.
The above terms are intended to assist readers’ interpretation of the report, and to
provide suitable explanations where uncertainty remains. The report should therefore
be interpreted as the view of RAIB, expressed with the sole purpose of improving
railway safety.
Any information about casualties is based on figures provided to RAIB from various
sources. Considerations of personal privacy may mean that not all of the actual effects
of the event are recorded in the report. RAIB recognises that sudden unexpected
events can have both short- and long-term consequences for the physical and/
or mental health of people who were involved, both directly and indirectly, in what
happened.
RAIB’s investigation (including its scope, methods, conclusions and recommendations)
is independent of any inquest or fatal accident inquiry, and all other investigations,
including those carried out by the safety authority, police or railway industry.
Report 01/2023 v2 February 2024
Lady Howard crossing
Pedestrian struck by a train at Lady Howard
footpath and bridleway crossing, Surrey,
21 April 2022
Contents
Preface4
Summary6
Introduction7
Definitions 7
The accident8
Summary of the accident 8
Context8
The sequence of events15
Analysis17
Identification of the immediate cause 17
Identification of causal factors 17
Identification of underlying factor 20
Previous occurrence of a similar character 26
Summary of conclusions27
Immediate cause 27
Causal factors 27
Underlying factor 27
Previous RAIB recommendations relevant to this investigation28
Actions reported as already taken or in progress relevant to this report when
originally published (v1.0)30
Actions reported as already taken or in progress relevant to this report when
it was revised (v2.0)31
Recommendations and learning point33
Recommendations33
Learning point 34
Appendices35
Appendix A - Glossary of abbreviations and acronyms 35
Appendix B - Investigation details 36
Report 01/2023 5 v2 February 2024
Lady Howard crossing
Summary
Summary
At about 14:49 hrs on Thursday 21 April 2022, a pedestrian was struck and fatally
injured by an out-of-service passenger train at Lady Howard footpath and bridleway
crossing, near Ashtead in Surrey. The pedestrian, who was walking on the crossing
with a dog and pushing a wheeled trolley bag, started to cross the railway tracks
shortly after a train had passed. She was struck by a second train, which was
travelling in the opposite direction to the first. The driver of the train involved in the
accident sounded the train’s horn on seeing the pedestrian on the crossing. The
pedestrian responded by hurrying forwards towards the exit of the crossing, but was
unable to get clear of the path of the train in time to avoid being struck.
RAIB’s investigation found that the pedestrian was apparently unaware that the
second train was approaching when she made the decision to cross; there is no
evidence that she was aware of it and/or had misjudged the time available to cross.
This was because, although the pedestrian looked twice in the direction of the second
train before starting to cross, the front of this second train was hidden behind the
first train, which was moving away on the line nearest to her. RAIB also found it was
possible that the pedestrian did not perceive the risk arising from the possibility that
the first train was hiding another approaching train.
A probable underlying factor was that Network Rail had not provided any effective
additional risk mitigation at the crossing, despite having previously deemed the risk to
users to be unacceptable. Network Rail had planned and budgeted to install integrated
miniature stop lights at the crossing, but a shortage of resource meant that delivery
was delayed. There is little evidence that Network Rail considered effective options
to mitigate the risk on an interim basis while this installation was pending, although
it fitted additional warning signs for users and a camera to monitor crossing use.
Network Rail had not considered applying for a derogation from an internal standard
which would have allowed it to fit a simpler version of miniature stop lights at the
crossing, although it is unlikely that this equipment would have been operational
before the accident, had such a derogation been obtained.
As a result of this investigation, RAIB has made two recommendations, both to
Network Rail. The first is intended to address the risk to pedestrians at crossings of
this type arising from a second approaching train being hidden from view by another
train. The second recommendation concerns the implementation of appropriate interim
risk mitigations at level crossings that are awaiting long-term solutions. RAIB has also
identified a learning point, addressing the need to consider whether a derogation from
standards is justified or has been approved previously.
Report 01/2023 6 v2 February 2024
Lady Howard crossing
Introduction
Introduction
Definitions
1 Metric units are used in this report, except when it is normal railway practice to
give speeds and locations in imperial units. Where appropriate the equivalent
metric value is also given.
2 The report contains abbreviations which are explained in appendix A. Sources of
evidence used in the investigation are listed in appendix B.
Report 01/2023 7 v2 February 2024
Lady Howard crossing
The accident
The accident
Summary of the accident
3 At about 14:49 hrs on Thursday 21 April 2022, a pedestrian was struck and
fatally injured by an out-of-service passenger train at Lady Howard footpath and
bridleway crossing, near Ashtead in Surrey (figure 1). The train was recorded as
travelling at about 62 mph (100 km/h) at the time of the accident.
4 The pedestrian, who was walking with a dog and a wheeled trolley bag, had
started to cross the railway tracks shortly after a previous train had passed the
crossing in the opposite direction to the train involved in the accident.
5 The driver of the train involved in the accident sounded the train’s horn upon
seeing the pedestrian on the crossing. The pedestrian responded to the warning
by hurrying forwards towards the exit of the crossing, but did not reach a point
that was clear of the train’s path before it arrived at the crossing.
Epsom station
Location of accident
Ashtead station © Crown Copyright. All rights reserved. Department for Transport 100039241. RAIB 2023
Figure 1: Extract from Ordnance Survey map showing location of accident at Lady Howard crossing.
Context
Location
6 Lady Howard crossing is situated in Surrey, between the stations at Epsom (1.3
miles (2.1 km) away) and Ashtead (0.7 miles (1.1 km) away). The line is used
by South Western Railway trains running from London Waterloo to Guildford
and Dorking, as well as Southern trains from London Victoria to Horsham. The
crossing is 15 miles 43 chains1 from a datum point at London Waterloo measured
via Worcester Park.
1
A unit of length equal to 66 feet or 22 yards (around 20 metres).
Report 01/2023 8 v2 February 2024
Lady Howard crossing
7 The railway at this location runs broadly north-east to south-west and comprises
The accident
two tracks, known as the up and down Portsmouth lines (towards and away from
London respectively; figure 2). An electrically live conductor rail, energised at 750
V DC, is located adjacent to each track to provide power to trains, although there
is a gap in the conductor rail at the crossing, for a distance of about three metres
either side of it. The maximum permitted speed for trains travelling in either
direction over the crossing is 60 mph (97 km/h). Signalling in this area is by colour
light signals, controlled from Wimbledon Area Signalling Centre. There is a signal
on each approach to the crossing, around 80 metres away for trains approaching
from Ashtead and 1200 metres away for trains approaching from Epsom.
8 The crossing itself is part of a footpath and bridleway linking Craddocks Avenue
in Ashtead (around 350 metres to the south-east of the crossing) to Ashtead
Common on the north-west side of the railway.
N
ndon
/ Lo
som
Direction of pedestrian Ep ain
To tr
n of
c tio
D ire
h line
out
o rtsm hl ine
UpP out
o rtsm
w nP
Do ead
ht
As
To
Figure 2: Google Earth view of the crossing.
Organisations involved
9 Network Rail is the owner and maintainer of the railway infrastructure at the
location of the accident, which includes Lady Howard crossing and the land inside
and including the boundary fences. It also employed the staff responsible for
gathering data about the crossing and for assessing and managing its safe use
(see paragraphs 27 and 28). Lady Howard crossing falls within Network Rail’s
Wessex route on its Southern region.
10 Govia Thameslink Railway, under its Southern brand, operated the train involved
in the accident as well as the train that passed the crossing in the opposite
direction just before the accident. It also employed the drivers of both trains.
11 Network Rail and Govia Thameslink Railway freely co-operated with the
investigation.
Report 01/2023 9 v2 February 2024
Lady Howard crossing
The level crossing
The accident
12 In common with many footpath and bridleway crossings (see paragraph 13), Lady
Howard crossing does not have any active protection, such as lights, to warn
of approaching trains, or barriers to restrict access over the crossing. Crossing
users on foot are expected to stop, look and listen for approaching trains, and
to make their own decision about whether or not it is safe to cross. Telephones
and instructions are provided for equestrian users to contact the signaller to ask
permission before crossing. This is because the railway perceives that there
is an additional risk involved in taking horses over a crossing of this type and
the mitigation of this risk involves the signaller checking whether any trains are
approaching the crossing before giving permission to cross.
13 Nationally, at the time of writing, there are 1336 crossings of the same type as
Lady Howard (as described in paragraph 12) on Network Rail’s infrastructure.
On the Wessex route, there are 154 such crossings, out of a total of 315 level
crossings.
14 On each side of Lady Howard crossing, users enter through a latched gate that
opens towards the railway. The gate leads users through the railway boundary into
a corridor laid with an asphalt surface. This corridor is enclosed with metal fencing,
approximately 1.25 metres tall. Signs at each gate warn users of the following:
• to ‘Stop, Look, Listen – Beware of trains’
• that cyclists should dismount
• that people in charge of animals should telephone the signaller before crossing
• that users should remove their headphones before crossing
• not to touch the live rail
• not to trespass on the railway
• that there have been several near fatalities at this crossing.
At the time of the accident, some of these signs had been painted with graffiti
(figure 3).
15 RAIB measured the fenced corridor inside the gate on the Ashtead Common side
of the crossing (the approach used by the pedestrian involved in the accident) to
be 4.5 metres long. This ends with a white line painted on the asphalt surface 2
metres from the nearest rail of the up Portsmouth line (figure 4). This white line,
known as the ‘decision point’, is the notional point at which users on foot are
expected to make a decision as to whether or not it is safe to cross the railway. For
crossing users with horses, Network Rail uses a decision point 3 metres from the
nearest rail, although this point is not marked on the ground.
16 At the marked decision point, the metal fencing opens out in both directions
along the railway. RAIB measured the sighting distances (the distances at which
approaching trains can be seen by crossing users) in each direction at this point.
On the Ashtead Common side, a user standing at the decision point can see for
around 440 metres in the direction towards Epsom (the direction from which the
train involved in the accident approached). Beyond this point the railway curves
to the left from the observer’s point of view (figure 5 and figure 6). In the other
direction, the railway is straight and users can see for at least 1000 metres to
Ashtead station.
Report 01/2023 10 v2 February 2024
Lady Howard crossing
The accident
Figure 3: The entrance to Lady Howard crossing, approaching from Ashtead Common (the direction of
the pedestrian at the time of the accident).
Direction of pedestrian
Figure 4: Inside the gate at Lady Howard crossing showing the decision point, approaching from Ashtead
Common.
Report 01/2023 11 v2 February 2024
Lady Howard crossing
The accident
Direction of train
Figure 5: View from the decision point on the Ashtead Common side of Lady Howard crossing, looking
towards Epsom.
N
Lady Howard crossing To Epsom
Direction of train
To Ashtead
Sighting point: 440 m
Figure 6: Google Earth view of the location, showing the crossing and the left-hand curve in the direction
towards Epsom.
Report 01/2023 12 v2 February 2024
Lady Howard crossing
17 The distance between the two decision points (located 2 metres from the
The accident
nearest rail on each side of the crossing) is known as the ‘traverse distance’.
RAIB measured this distance to be 9.3 metres. Because Lady Howard is also a
bridleway crossing, Network Rail’s measurement of the traverse distance starts
at the decision point 3 metres from the nearest rail (paragraph 15) and ends 2
metres beyond the farthest rail. Network Rail measured the traverse distance to
be 10.2 metres, which is comparable to RAIB’s measurement (accounting for the
additional metre).
18 Network Rail uses the traverse distance to calculate the amount of time it takes
a user to cross. Network Rail uses a defined walking speed of 1.189 m/s for
this calculation which, in some instances (including at Lady Howard crossing),
is reduced by 50% to allow for vulnerable users (such as families with young
children, dog walkers, or the elderly, who may walk slower). Including this 50%
allowance results in a traverse time of 12.87 seconds. This is therefore the
minimum required sighting time in each direction for trains approaching the
crossing at the maximum permitted speed on the line (in this case, 60 mph or 97
km/h). A train at that speed will cover 345 metres in that time; hence, this is the
minimum sighting distance that users require to decide if it is safe to cross.
19 Because the actual sighting distance exceeds the required sighting distance on
both sides of Lady Howard crossing (440 metres towards Epsom and over 1000
metres towards Ashtead), there is no requirement for the crossing to be fitted with
any type of additional protection that may be used for reduced sighting distances,
such as a whistle board instructing train drivers to sound the train horn on the
approach to the crossing.
20 Network Rail’s most recent risk assessment (see paragraph 57) for Lady Howard
crossing before the accident (dated October 2021) noted that an average of 201
users and 225 trains per day passed over the crossing. Users were identified as
mainly being recreational, using the crossing to access Ashtead Common.
21 Network Rail assesses the risk of all its level crossings on two criteria. These are:
• the risk to an individual user of the crossing (rated from A to M, where A is the
highest risk)
• the total, collective risk of harm to crossing users and those on board trains
(rated from 1 to 13, where 1 is the highest risk).
The October 2021 risk assessment for Lady Howard crossing rated it as B2,
ranking it the sixth highest risk footpath crossing on the Wessex route.
22 The October 2021 risk assessment documented six near misses at the crossing
between 28 March 2019 and 29 March 2021 and one fatality on 9 August
2019, which Network Rail recorded as a deliberate act. The October 2021 risk
assessment also recorded that Network Rail installed a motion-activated camera
at the crossing, in response to a number of incidents that it classified as deliberate
misuse.
Report 01/2023 13 v2 February 2024
Lady Howard crossing
Trains involved
The accident
23 The train involved in the accident, reporting number 5Z56, was the 14:05 hrs
empty coaching stock movement (a train movement without passengers) from
Selhurst depot to Dorking down sidings. It was a class 377 train formed of 10
coaches. The train was fitted with an on-train data recorder (OTDR) but not with
forward-facing CCTV (FFCCTV) cameras.
24 The train which passed the crossing just before the accident, reporting number
1I37, was the 14:14 hrs passenger service from Horsham to London Victoria. It
was also a class 377, formed of 8 coaches. This train was fitted with an OTDR
as well as an FFCCTV camera, but not a camera looking behind the train. This
means that there was no rearward-facing CCTV evidence available.
People involved
25 The pedestrian was an 85-year-old female from Hampton, south-west London.
Her eyesight prescription showed that she had a mild astigmatism (a cause of
blurred vision that can be corrected with glasses or contact lenses), but good
distance vision. She also used a hearing aid and, while her mobility was good,
the trolley she used was described to RAIB as also acting as an aid to standing.
Although RAIB could not establish with certainty whether the pedestrian was
familiar with the crossing, the circumstances suggest that, while she was unlikely
to have used it regularly, it is possible that she had used it before.
26 The driver of train 5Z56 was based at Selhurst depot and had worked for
Southern since November 2001. His competence assessments were up to date
with positive feedback about his performance and no reported issues of concern.
27 The level crossing manager (LCM) with responsibility for Lady Howard crossing
had worked for Network Rail since 2000, with the exception of one year working
for a train operator. He had worked as an LCM in this area since 5 November
2018. Lady Howard was one of around 48 crossings that fell within his area of
responsibility.
28 The route level crossing manager (RLCM) for Wessex route, to whom the LCM
reported, joined Network Rail in 2003 and began managing level crossings
about two years later. He had been RLCM for about 10 years and, at the time
of the accident, managed a team of five LCMs. Since the accident (but not as a
response to it), Network Rail’s Wessex route has restructured the organisation of
these roles, and the RLCM now works at a regional level.
External circumstances
29 The weather at the time of the accident was sunny and warm, about 18°C, with
clear visibility. The sun was to the right of the pedestrian as she approached the
crossing (in the direction towards Ashtead), the same direction from which the
train that passed the crossing just before the accident approached. It is possible
that the sunlight played a role in the accident (see paragraph 46).
Report 01/2023 14 v2 February 2024
Lady Howard crossing
The sequence of events
The sequence of events
Events preceding the accident
30 At around 14:33 hrs on the day of the accident, Network Rail’s camera at Lady
Howard crossing recorded the pedestrian using the crossing for the first time that
day. The pedestrian was walking towards Ashtead Common with a dog and a
wheeled trolley bag.
31 At 14:49:06 hrs, the front of train 1I37 passed over Lady Howard crossing,
travelling towards Epsom on the up Portsmouth line (from right to left when
viewed from the Ashtead Common side of the crossing) at a speed of
approximately 50 mph (80 km/h). As the train passed the crossing, its FFCCTV
system recorded the pedestrian standing, stationary, waiting inside the boundary
gate on the Ashtead Common side of the crossing, about 1.9 metres back from
the white line marking the decision point and looking towards the oncoming train.
The field of view of the camera at the crossing also showed the dog waiting
stationary while train 1I37 passed the crossing.
32 Around one second after the front of train 1I37 passed the crossing, the front of
train 5Z56 emerged round the curve on the down Portsmouth line. Train 5Z56
was about 440 metres from Lady Howard crossing at that time, travelling from
the Epsom direction, and would have been visible from the crossing. After about
6 seconds, from the point of view of someone standing on the Ashtead Common
side of the crossing, the front of the approaching train 5Z56 would have been
obscured behind train 1I37 as it moved away.
33 Less than one second later, the rear of train 1I37 had cleared Lady Howard
crossing, and the pedestrian started to move towards the decision point. The
camera at the crossing showed that she briefly turned her head to the left as she
started to move forwards and did so again as she crossed the decision point.
During both of these glances, the front of train 5Z56 would have been hidden
behind train 1I37. The pedestrian crossed the decision point about 4 seconds
after train 1I37 had cleared the crossing.
Events during the accident
34 Around one second after the pedestrian crossed the decision point, the front of
train 5Z56 emerged from behind train 1I37 and would have been visible from the
crossing. The crossing would also now have been visible from the driving cab of
the train. At this point, OTDR evidence shows that train 5Z56 was travelling at 62
mph (100 km/h) and that it was about 130 metres, or approximately 4.7 seconds,
from the crossing. CCTV evidence from the crossing shows that the pedestrian
was at that point moving across the up Portsmouth line, and that she was looking
down and ahead.
35 Approximately 2.7 seconds later, the driver of train 5Z56 sounded the train’s horn.
The pedestrian, by now about to cross the down Portsmouth line, responded
by looking to her left and starting to hurry across this line towards the exit of the
crossing. The collision occurred at about 14:49:24 hrs.
Report 01/2023 15 v2 February 2024
Lady Howard crossing
Events following the accident
The sequence of events
36 The pedestrian sustained injuries that were immediately fatal. The driver applied
the emergency brake just over one second after the collision, and the train
subsequently stopped about 315 metres beyond the crossing. The driver used the
GSM-R (Global system for mobile communications – railway) train radio system to
report the accident to the signaller and subsequently reported it to his employer.
37 Emergency services and Network Rail staff attended the scene from around 15:20
hrs. The driver was authorised to take the train on to Ashtead station where he
was relieved, and another driver returned the train to Selhurst depot.
Report 01/2023 16 v2 February 2024
Lady Howard crossing
Analysis
Analysis
Identification of the immediate cause
38 The pedestrian crossed into the path of train 5Z56 as it approached.
39 The FFCCTV footage from train 1I37 and images from the CCTV camera at the
crossing (paragraph 22) showed that the pedestrian had waited for train 1I37 to
pass the crossing, and that she then crossed behind it, having looked twice to her
left before passing the decision point. The pedestrian did not look again to her left
until she heard the horn of train 5Z56, after which she attempted to hurry to the
other side of the crossing.
40 RAIB determined that the driver’s reaction time in sounding the horn after seeing
the pedestrian, which at most was about 2.7 seconds, was within the bounds
of an appropriate response based on research2 into car drivers’ reaction times.
Furthermore, if the driver had applied the train’s emergency brake instead of (or
as well as) the horn, it would have had no effect on the train’s speed before the
accident because the nature of the train’s braking system means that there is
a delay of about 3 seconds between applying the brakes and the beginning of
deceleration. Finally, the apparent discrepancy between the train’s speed of 62
mph (100 km/h) as recorded on the OTDR on approach to the crossing, and the
maximum permitted speed on that line of 60 mph (97 km/h), is within the margin of
tolerance allowed in rail industry standards.3
Identification of causal factors
41 The accident occurred due to a combination of the following causal factors:
a. The pedestrian was apparently unaware that train 5Z56 was approaching
when she made the decision to cross (paragraph 42).
b. The pedestrian did not perceive the risk arising from the possibility that the
passing train was hiding another train (paragraph 48). This is a possible
causal factor.
Each of these factors is now considered in turn.
Awareness of the train
42 The pedestrian was apparently unaware that train 5Z56 was approaching
when she made the decision to cross.
43 Based primarily on the CCTV evidence from the camera at Lady Howard crossing
(paragraph 22), RAIB has concluded that the pedestrian had probably neither
seen nor heard the approach of train 5Z56 when she started to cross. There is no
evidence to suggest that she was aware of this second train when she made the
decision to cross, or that she was aware of it but had misjudged the time available
to cross safely.
2
Coley, G., Wesley, A., Reed, N. & Parry, I. (2009). Driver reaction times to familiar but unexpected events. TRL
Report 313.
3
RIS-2273-RST ‘Post Incident and Post Accident Testing of Rail Vehicles’, issue 2, December 2017.
Report 01/2023 17 v2 February 2024
Lady Howard crossing
44 RAIB created a computer model of the two trains passing at the crossing, to
Analysis
determine what may or may not have been visible to the pedestrian at the
two points when she looked to the left, towards the approaching train 5Z56
(paragraph 35). The model was based on the OTDR evidence from both trains,
FFCCTV footage from train 1I37, footage from the CCTV camera at the crossing,
and RAIB’s survey data for the crossing. Because the OTDR and CCTV data
sources are not synchronised, and must be cross-referenced manually, there is a
small level of inaccuracy (fractions of seconds) possible with this kind of analysis.
However, RAIB has determined that the conclusions which follow reflect the best
available evidence.
45 When the pedestrian looked twice to the left, the front end of train 5Z56 (which
is the most conspicuous part of the train, being painted yellow and displaying
headlights) was hidden behind train 1I37, which was receding from the crossing.
The front end of train 5Z56 did not re-emerge from behind 1I37 until after the
pedestrian had started to cross. Although it may have been possible for the
pedestrian to have seen the side of train 5Z56 in the gap beyond train 1I37 and
before the railway curved to the left out of view, it would have appeared very small
at that distance and not particularly conspicuous (figure 7). This is in part because
the green and white painted livery of the train would have provided relatively low
contrast against the background of green vegetation.
46 The pedestrian was wearing prescription sunglasses and had been facing towards
Ashtead just before crossing, in the direction of the approaching train 1I37. In that
position and at that time of day, she was almost directly facing the sun. When
she turned to look towards the left, there may have been some after- effects of
facing the sun that could have reduced her sensitivity to contrast, and this may
have been further attenuated by the sunglasses. However, the predominant factor
affecting the pedestrian’s ability to see the oncoming train 5Z56 was the presence
of train 1I37 as it moved away from the crossing. This would have been much
more conspicuous and largely hid the approaching train, 5Z56, from view.
Train 1I37
Train 5Z56
Figure 7: Computer-generated reconstruction of the view from the pedestrian’s perspective looking to
her left as she started moving towards the crossing.
Report 01/2023 18 v2 February 2024
Lady Howard crossing
47 The driver of train 5Z56 did not, nor was he required to, sound the train’s horn on
Analysis
the approach to the crossing, until a few seconds before the accident when he
reacted to seeing the pedestrian ahead. In the absence of a train horn, the noise
generated by an electric train at distance is relatively inconspicuous, and again
would have been masked by the similar noise being produced by train 1I37, which
was closer. The pedestrian also used a hearing aid, although her prompt response
to the train’s horn when it sounded just before the accident indicates that she was
able to hear this warning.
Perception of risk
48 The pedestrian did not perceive the risk arising from the possibility that the
passing train was hiding another train. This is a possible causal factor.
49 Among the signage at the crossing is an instruction for users to ‘Stop, Look, Listen
– Beware of trains’. The CCTV evidence shows that the pedestrian did stop for
the first train passing the crossing (1I37) and then looked twice to the left before
starting to cross.
50 When the pedestrian took the second glance, as she passed the decision point,
RAIB calculated that the rear of train 1I37 was around 100 metres beyond the
crossing. RAIB has also concluded that, at that point, it is more likely than not that
the pedestrian would have been looking towards her left for oncoming trains on
the down Portsmouth line to the right of, rather than beyond the front of train 1I37
and into the diminishing gap between it and the curve of the railway line.
51 Visibility past the trailing end of train 1I37 towards the down Portsmouth line would
have been greater than 100 metres (figure 8). Given the extent of the visibility
available to the pedestrian, it is possible that she decided that this was sufficient
distance to be able to safely traverse the crossing, not realising that a train
travelling at the maximum permitted speed of 60 mph (97 km/h or 27 m/s) could
cover the visible distance in around 4 seconds. At the time of the accident, there
were no warnings at the crossing to alert users to this risk.
Train 1I37
Figure 8: Computer-generated reconstruction of the view from the pedestrian’s perspective looking to
her left as she crossed the decision point.
Report 01/2023 19 v2 February 2024
Lady Howard crossing
Identification of underlying factor
Analysis
Risk management
52 Network Rail had not provided any effective additional risk mitigation at
the crossing despite having deemed the risk to be unacceptable. This is a
probable underlying factor.
Background information
53 The Office of Rail and Road (ORR), the safety authority and economic regulator
for Britain’s railways, has set out principles and guidance for managing level
crossing safety in a document4 published in June 2021. This document includes
guidance that states ‘It is essential that decisions and options for level crossing
control measures are informed by a suitable and sufficient assessment of the
risks’.
54 Under health and safety law, duty holders (in the case of this crossing, Network
Rail) are required to reduce the level of risk so far as is reasonably practicable.
Options for controlling the risk should be considered according to the hierarchy
of prevention5 Eliminating the risk (such as through closure of the level crossing)
should be the first consideration, followed by engineering controls (for instance,
technologies providing an active warning system), and finally administrative
controls (such as signage and instructions).
55 Deciding what is reasonably practicable is a matter of judgement for each duty
holder but, given the risks to railway staff, passengers and members of the public,
the ORR guidance document states that risk control measures should be deemed
reasonable unless the cost of the measure is grossly disproportionate to the
risk. This can be determined by using a cost-benefit analysis as part of the risk
management process.
56 The ORR guidance document also includes a principle which states:
‘User Principle 6: Provide a suitable warning for users that a train is
approaching to enable them to be in a safe place before a train passes. To help
you achieve this, you should consider, at least, these factors:
(a) an active warning system in preference to relying on the user to determine
whether or not a train is approaching the level crossing;
(b) user behaviours and actions in relation to the operation of the level crossing,
e.g. to prevent them from being trapped within a closed crossing or starting
to cross when it is unsafe to do so
(c) foreseeable actions of different users in a ‘another train coming’ scenario,
these trains may be coming in the same or different directions; one may be
inaudible and hidden from view…’
57 Network Rail’s process for managing risk at level crossings begins with an
assessment by an LCM of the crossing. This includes measuring sighting
distances and the traverse length and conducting a census of both users and
trains over the crossing. The results of this assessment are entered into Network
Rail’s computer-based all level crossing risk model (ALCRM), which calculates a
quantitative risk score for the crossing (paragraph 21).
4
https://www.orr.gov.uk/sites/default/files/2021-06/principles-for-managing-level-crossing-safety-june-2021_0.pdf.
5
The Management of Health and Safety at Work Regulations 1999, schedule 1.
Report 01/2023 20 v2 February 2024
Lady Howard crossing
58 The LCM uses the information from the site visit and the output from ALCRM to
Analysis
produce a written narrative risk assessment (NRA). The NRA documents their
findings and, if the risks are deemed not to be as low as reasonably practicable,
proposes options to mitigate the risk. The quantitative risk score from ALCRM is
used to calculate a cost-benefit ratio for each of the proposed risk mitigations.
The cost-benefit ratio is a whole-life calculation of how much each proposed
measure costs6 and by how much it is expected to reduce the risk. The LCM then
uses their experience and professional judgement to supplement this calculation
and determine whether the options are reasonably practicable to implement,
considering qualitative factors associated with risk at the crossing as well as the
results of any cost-benefit analysis.
59 The LCM submits the NRA and their risk mitigation option proposals to the RLCM,
who reviews and (as appropriate) countersigns them. In Network Rail’s Wessex
route, the RLCM takes these options, along with those for other level crossings,
to a four-weekly ‘tactical group’ meeting, which also involves the route’s asset
managers for signalling and scheme renewals. This tactical group takes decisions
about which options are progressed, based on the available funding and the route
level crossing strategy.
60 The latest level crossing strategy for Network Rail’s Wessex route before the
accident (dated January 2019) covers the period from 2019/20 to 2023/24. While
the previous route strategy focused on closing level crossings where possible, the
emphasis of the strategy in force at the time of the accident was on reducing risk
through engineering solutions as part of upgrades or renewals, where closure is
difficult or impossible. The strategy is supported by its own, ring-fenced budget
which can only be used for level crossing risk reduction in accordance with the
strategy. The ORR has made additional funds available which are prioritised
towards risk reduction at user worked crossings (a type of level crossing typically
providing vehicular access to private land).
61 Closing a crossing outright (that is, closing it without providing alternative access
over the railway at that location) is not always viable because it can involve issues
such as extinguishing legal rights of way, or the consequent increased risk on
diversionary routes. The main alternative options to outright closure are to install
a footbridge (which, for a bridleway crossing, needs to include ramps to provide
access for people with reduced mobility or horse riders) or to install miniature stop
lights (MSLs).
62 MSLs consist of red and green lights. The green light is lit the majority of the time
and indicates that no trains are approaching. When a train reaches the strike
in point the light automatically changes to red, and an audible alarm sounds
to indicate that users must not cross. The strike in point is set at a distance
calculated to allow users a safe amount of time to cross when trains are travelling
at the maximum speed permitted on the line. Network Rail told RAIB that the
audible alarm also includes a spoken warning which is triggered if another train
is approaching the crossing soon after the first one has passed. This message
states ‘Warning – another train may be approaching’.
6
In May 2022, Network Rail issued new guidance on these cost-benefit analyses, raising the threshold for what is
considered reasonably practicable by stating that mitigations should be considered for implementation unless the
costs are ‘grossly disproportionate’ to the benefits. This change was not made in response to this accident.
Report 01/2023 21 v2 February 2024
Lady Howard crossing
63 There are different types of MSL system, each of which is appropriate for different
Analysis
level crossing configurations:
• ‘Integrated MSL’. These were the original design of MSL and are built into the
railway signalling system, which makes them costly and complex to install.
However, as they form part of the signalling system, they are suitable for any
location, including those where signals and stations lie between crossings and
their strike in points. If a train is held at a signal or station, signalling controls
are applied to prevent the red light from showing at the crossing until the train
is about to start moving again. This avoids excessive warning times (see
paragraph 66).
• ‘Overlay MSL’. These were introduced from around 2012 and are separate
from the railway signalling system. They can be installed at locations where the
railway does not have complex features, such as nearby stop signals. These
MSLs use a basic train detection system which detects trains a set distance
along each railway approach to the crossing.
• ‘Flex MSL’. These were approved for use by Network Rail in April 2021 and use
the same technology as overlay systems but can receive inputs from a signal on
each approach to a crossing. This allows them to be installed at locations where
trains may be regularly stopped by a signal within the strike in area.
64 Section 5.1.3 of Network Rail standard NR/L2/SIG/11201/ModX39, published in
June 2015, and later revisions of this standard, state that overlay MSL systems
are not suitable for crossings which have signals within the strike in area, as well
as other complicating features.
65 Section 5.2 of this standard requires that 50% of trains arrive at overlay MSL
crossings within twice the normal warning time (the warning time is generally 20
to 40 seconds, depending on the crossing) and 95% of trains arrive within three
times the normal warning time.
66 If the time between strike in and the train arriving at the crossing is longer than
designed, it can result in red lights being displayed for prolonged periods and/or
the overlay MSL system going into what is known as ‘dark mode’, where it turns
off the lights at the crossing and waits for the passage of another train to reset
itself. Frequent long warning times or occurrences of dark mode are unacceptable
as they potentially diminish level crossing users’ faith in, and compliance with, the
red and green lights at the crossing. This means that, in principle, overlay MSLs
are not suitable where there are signals which could regularly delay a train’s
arrival at the crossing.
67 In common with many other Network Rail standards, NR/L2/SIG/11201/ModX39
is colour coded with a Red-Amber-Green classification. Red boxed sections are
mandatory, with no variations permitted, while sections with an amber colour
coding may be varied if a risk assessment is submitted and approved following
a national process. Green colour coded sections are guidance which should be
used, unless a better alternative is available.
Report 01/2023 22 v2 February 2024
Lady Howard crossing
68 Sections 5.1.3 and 5.2 of NR/L2/SIG/11201/ModX39 have an amber colour
Analysis
coding. This means that designers could have applied for a derogation from the
standard’s requirement to not have any signals within the strike in area, provided
a suitable risk assessment was prepared which demonstrated that the installation
would provide an equivalent level of safety. This risk assessment would have to
be approved by a national review panel before the derogation was granted. In the
case of Lady Howard crossing, the designers would have needed to demonstrate
that the signals on the approach to the crossing would delay the arrival of less
than 5% of the trains approaching the crossing.
69 Another option for mitigating level crossing risk is to install supplementary
audible warning devices (SAWDs). Using radar to detect an approaching train,
these devices play a synthesised recording of a train horn through a speaker
at the crossing itself. Because the reliability of SAWDs does not meet Network
Rail’s standards for safety-critical systems, Network Rail considers them to be
supplementary to an actual train horn. As such, SAWDs are only installed at
crossings where whistle boards are provided, requiring the train driver to sound
the horn because sighting distances are insufficient to provide the necessary
warning time. The synthesised recording is triggered at about the same time as
the sounding of the actual train horn.
Risk management at Lady Howard crossing
70 The latest NRA for Lady Howard crossing undertaken before the accident, dated
October 2021, expressed concerns about vulnerable users and frequent misuse.
The installation of additional signage (see paragraph 83) and the crossing camera
(paragraph 22) were intended as short-term mitigation measures for these
concerns. In the medium term, the NRA stated that installing MSLs was being
progressed and, in the longer term, that Network Rail’s aspiration was to close
the crossing. However, in the meantime, the NRA stated that the risk was not
considered to be as low as reasonably practicable. Similarly, the previous NRA in
2020 referred to the risk being ‘unacceptable’.
71 The 2021 NRA considered four options to mitigate the risk. These were closure, a
ramped (accessible) footbridge, a stepped footbridge, or MSLs. Although the cost-
benefit calculations for closure and a stepped footbridge were positive, the LCM
concluded that these options were not viable. This was because, if Lady Howard
crossing was closed, its risk would be transferred to the nearby Craddocks Lane
footpath crossing, about 380 metres towards Ashtead station. The LCM also
considered that gaining the necessary consent and approval for a ramped bridge
would be unlikely, due to the size of such a bridge taking it outside of Network
Rail’s land, and that a stepped footbridge would neither be accessible nor suitable
for equestrian users.
Report 01/2023 23 v2 February 2024
Lady Howard crossing
72 The LCM therefore recommended installing MSLs, even though the cost-benefit
Analysis
ratio for this option was marginal.7 RAIB has reviewed NRAs for Lady Howard
crossing going back to 2017, and on each occasion the recommendation made
was to install MSLs. The evidence available to RAIB indicates that Network Rail
had approved and allocated funds for installing MSLs at Lady Howard crossing
every year since at least 2019, when budgets for Network Rail’s control period 6
(a five-year financial allocation running from April 2019 to March 2024) had been
allocated.
73 In 2020, Network Rail’s Wessex route engaged its internal works delivery unit
to produce an option selection report to determine the best type of MSL to be
installed at Lady Howard level crossing. Network Rail has not been able to locate
nor provide RAIB with a copy of the option selection report. However, internal
meeting minutes from December 2020, after the report had been completed,
recorded a decision to fit integrated MSLs to the crossing and gave financial
approval for this.
74 RAIB considers that it is most likely that the option selection report concluded
that integrated MSLs were the best option because there is a railway signal on
each approach to Lady Howard crossing. This would have probably led those
responsible for writing the report to conclude that the site was not compatible
with the overlay MSL system. At the time the report was completed, there was
no suitable alternative form of MSLs available for locations with this kind of more
complex layout (paragraph 63).
75 Following the completion of the option selection report, its recommendations were
reviewed by Network Rail’s Wessex route’s level crossing steering group, which
consists of senior members of the level crossing and signalling teams. Financial
approval was given for Lady Howard to be upgraded with integrated MSLs and
this work was expected to be completed in the second half of control period 6.
Once the budget had been allocated, Network Rail’s Wessex route accepted the
level of risk at Lady Howard until such time as integrated MSLs could be installed.
76 There is no conclusive evidence which shows if the authors of the option
selection report were aware that it would have been possible to fit overlay MSLs
to locations such as Lady Howard, rather than the proposed integrated MSLs,
via a derogation from standard NR/L2/SIG/11201/ModX39 (paragraph 68). This
approach had been used five times in 2017 by Network Rail’s Sussex and Kent
routes, and these previous derogations would have been visible to the authors
of the option selection report if they had checked Network Rail’s standards
derogation tracker (which lists all approved derogations). As RAIB has not been
provided with a copy of the options selections report, it is not possible to know
for certain whether the tracker was checked as part of its preparation. However,
RAIB considers that the decision to fit integrated MSLs means it is probable that
the report’s authors were not aware of these earlier derogations.
7
RAIB reviewed the cost-benefit calculations and identified some inconsistencies in the analysis, which Network
Rail was unable to resolve. Since these inconsistencies did not affect subsequent safety-related decision-making
for Lady Howard crossing, RAIB determined that they were not causal to the accident. However, under different
circumstances, these calculations may be pivotal to such decision-making.
Report 01/2023 24 v2 February 2024
Lady Howard crossing
77 In July 2021, Network Rail’s Wessex route’s level crossing steering group
Analysis
reported that it had a shortage of resource within its works delivery unit and that
the delivery date for the integrated MSL at Lady Howard crossing was likely to be
delayed. This meant that design work was not expected to start until the autumn
of 2021.
78 In October 2021, around the revised time design work had been expected to start
on the integrated system, the Flex MSL was identified as a viable option for Lady
Howard crossing. This followed the trial installation and approval of this type of
MSL at another Wessex route level crossing. The decision to install this type of
system instead of an integrated MSL at Lady Howard was confirmed in January
2022 by the Wessex level crossing steering group.
79 In the time between the completion of the option selection report and the
accident, of the twelve other level crossings selected for conversion to MSLs on
the Wessex route, two were removed from the programme (due to one being
closed and the other receiving other upgrades) and one overlay MSL was brought
into use. This rate of completion meant that it was unlikely that Lady Howard
would have been upgraded with overlay MSLs before the accident, even if it had
been selected as part of the option selection process in 2020 and then been the
subject of a successful derogation application.
80 Network Rail stated it had faced issues in delivering MSLs at a national level.
This is because many of the level crossings that were feasible for closure have
already been closed, meaning that LCMs were frequently relying on MSLs as a
risk mitigation. (RAIB has seen several examples of other NRAs, similar to those
undertaken for Lady Howard, in which the options of closure or a footbridge are
not deemed to be viable, leaving MSLs as the recommended solution.) This has
created high demand for both the equipment and the resources to install the MSL
systems and reduced their availability, thereby slowing delivery programmes.
81 The 2021 NRA for Lady Howard crossing also identified the ‘second train coming’
risk (sometimes referred to as ‘another train coming’), in which an approaching
train can be hidden by a passing train on the nearest line, as occurred in
this accident. This risk is present on any railway with two or more tracks and
increases with the frequency of train traffic, but it is almost impossible to
determine where trains will actually pass each other. As with other NRAs seen by
RAIB, while the risk is identified, it is not specifically addressed or controlled in the
conclusions and proposed options, partly because there are few options available
to mitigate this risk. Although MSLs may be effective at addressing the second
train coming risk, these warnings may not entirely eliminate it, because they are
dependent on users recognising the warning, understanding its significance, and
then acting upon it. Recognition may be affected if the user is hearing impaired or
wearing headphones.
Interim risk mitigations
82 Although Network Rail had recognised that the risk at Lady Howard crossing was
unacceptable, and that a suitable mitigation solution would not be installed for
a minimum of three years, there is little evidence that alternative options were
considered as an interim measure to reduce risk to crossing users.
Report 01/2023 25 v2 February 2024
Lady Howard crossing
83 Network Rail had implemented some mitigations at Lady Howard crossing, but
Analysis
these did not prevent the accident on 21 April 2022. Between August 2019 and
July 2020, Network Rail installed additional signs at Lady Howard crossing, which
were intended to raise awareness of the risks of near misses and to warn users
to remove headphones before crossing (figure 3). The 2021 NRA also recorded
the installation of the motion-activated camera, primarily to monitor misuse of the
crossing. These signs and the camera were in place at the time of the accident.
84 Train drivers are not required to sound the horn at Lady Howard crossing because
the sighting affords sufficient warning time to be able to cross safely (paragraph
19). There is no evidence that this was considered as an interim mitigation before
the accident occurred. Network Rail is mindful of the noise pollution associated
with train horns, particularly in residential neighbourhoods. In the absence of a
requirement to sound the train horn, Network Rail also considers SAWDs to be
unsuitable because they are only intended to be supplementary to the train horn
(paragraph 69).
85 In other locations on Network Rail’s infrastructure, temporary speed restrictions
have been applied as an interim risk mitigation for level crossings, as slowing
trains down increases the warning time for crossing users. These are usually
used to mitigate the risk of insufficient sighting at the crossing, for example, due
to foliage growth reducing a crossing user’s view. Although it cannot be known for
certain what effect a temporary speed restriction would have had on this particular
accident, it is possible that it would reduce the likelihood of a user being struck.
86 There is no evidence that speed restrictions were considered as an interim
mitigation for the risks at Lady Howard crossing despite the risk at the crossing
being deemed unacceptable (paragraph 70). While it is not clear why speed
restrictions were not considered as a mitigation measure, Network Rail stated
to RAIB that the introduction of speed restrictions to address the second train
coming risk could potentially extend to a large number of crossings and cause
very significant disruption to railway operations.
Previous occurrence of a similar character
87 At about 08:24 hrs on 1 May 2019, the driver of the 07:25 hrs passenger service
from London Victoria to Horsham reported a near miss with a pedestrian with a
bicycle at Green Lane footpath crossing, about 0.5 miles (0.8 km) south-west of
Ashtead. The latest NRA for Green Lane (dated April 2022 and carried out by the
same LCM that undertook the assessment at Lady Howard crossing) recorded
that the pedestrian walked out from behind another passing train.
88 The NRA recorded the risk rating for Green Lane as C2 and stated that this
ranked it as the second highest risk of all footpath crossings on the Wessex
route. The LCM concluded that the risk was not tolerable or as low as reasonably
practicable. As with the NRA for Lady Howard, the NRA for Green Lane also
identified the ‘second train coming’ risk, highlighting that this risk is exacerbated
by the use of longer 10- and 12-coach trains on this line and the frequency of the
train service. As with Lady Howard crossing, no specific mitigations to address
this risk were identified or implemented, although the LCM recommended that
Green Lane crossing should be closed because of different circumstances
relating to access rights over the crossing.
Report 01/2023 26 v2 February 2024
Lady Howard crossing
Summary of conclusions
Summary of conclusions
Immediate cause
89 The pedestrian crossed into the path of train 5Z56 as it approached (paragraph
38).
Causal factors
90 The causal factors were:
a. The pedestrian was apparently unaware that train 5Z56 was approaching
when she made the decision to cross (paragraph 42, Recommendation 1).
b. The pedestrian did not perceive the risk arising from the possibility that the
passing train was hiding another train (paragraph 48, paragraph 101 and
Recommendation 1). This is a possible causal factor.
Underlying factor
91 Network Rail had not provided any effective additional risk mitigation at the
crossing despite having deemed the risk to be unacceptable (paragraph 52,
Recommendations 1 and 2, Learning point 1). This is a probable underlying
factor.
Report 01/2023 27 v2 February 2024
Lady Howard crossing
Previous RAIB recommendations relevant to this
Previous RAIB recommendations relevant to this investigation
investigation
92 The following recommendations, which were made by RAIB as a result of its
previous investigations, have relevance to this investigation.
Fatal accident at Gipsy Lane footpath crossing, Needham Market, Suffolk, 24 August
2011, RAIB report 15/2012, Recommendation 3
93 This recommendation read as follows:
Recommendation 3
The intent of this recommendation is for Network Rail to develop guidance
for use by the level crossing teams on the circumstances under which short-
term mitigation measures are to be implemented at level crossings that have
insufficient sighting or warning of approaching trains.
Network Rail should develop its guidance for use by level crossing teams to
include:
• a clear definition of what constitutes a ‘higher than usual’ number of vulnerable
users;
• implementing risk-reduction measures at crossings that have deficient sighting
or warning times; and
• when speed restrictions must be imposed, what type of speed restriction
is to be used (emergency, temporary or permanent) and the timescales for
imposing speed restrictions.
94 Network Rail’s response to this recommendation focused largely on developing
guidance to identify and calculate the proportion of vulnerable users of its level
crossings and producing guidance on interim risk mitigation for level crossings
with deficient mitigation. On 9 June 2014, ORR reported to RAIB that it
considered the recommendation to be implemented.
95 The relevance of this recommendation to the current investigation lies in the
short-term risk reduction measures for level crossings with insufficient warning of
approaching trains. Although sighting at Lady Howard was sufficient under normal
circumstances, the causal factors of the accident were associated with insufficient
warning of the second train. Therefore, recommendation 2 of this report takes a
broader approach to interim risk mitigations at high-risk level crossings.
Report 01/2023 28 v2 February 2024
Lady Howard crossing
Fatal accident at Tibberton No. 8 footpath crossing, 6 February 2019, RAIB report
Previous RAIB recommendations relevant to this investigation
13/2019, Recommendation 1
96 This recommendation read as follows:
Recommendation 1
The intent of this recommendation is for Network Rail to understand the risk to
crossing users presented by fog at passive level crossings and to ensure that
the risk to an individual using a passive level crossing in fog is acceptably low.
Network Rail should analyse and evaluate the risk of fog affecting the safe use
of those passive level crossings where users are entirely reliant on the sighting
of trains. This analysis should take into account regional and local variation of
the likelihood of fog, its potential impact on visibility and the effectiveness of
any existing mitigation measures. Network Rail should then use the output of
this evaluation to develop and implement a strategy to adequately mitigate the
effects of fog at passive level crossings.
97 Network Rail’s response focused on developing a tool to identify passive level
crossings that were historically vulnerable to fog, and on including that tool within
the NRA process. The response included consideration of MSLs to mitigate
sighting deficiencies but noted the problems in deployment of a wider solution.
Network Rail also engaged with industry about the possibility of using whistle
boards as a further means of reducing risk where reduced visibility is known to
occur.
98 On 6 December 2021, ORR reported to RAIB that it considered the
recommendation to be implemented.
99 Although the recommendation concerned a causal factor associated with foggy
weather conditions, the factor is analogous to the restricted sighting associated
with the second train coming risk which led to the accident at Lady Howard
crossing on 21 April 2022.
Report 01/2023 29 v2 February 2024
Lady Howard crossing
Actions reported as already taken or in progress relevant to
Actions reported as already taken or in progress relevant to this report when originally published (v1.0)
this report when originally published (v1.0)
100 From 25 May to 1 June 2022, Network Rail posted staff at Lady Howard crossing
for 12 hours a day over a period of seven days to talk to users about how to use
the crossing safely. On 26 October 2022, Network Rail delivered a presentation to
Ashtead Residents’ Association about level crossing safety.
101 On 11 October 2022, Network Rail erected a poster on the approaches to Lady
Howard crossing warning users that a passing train can obstruct the view of a
train coming on the other line (figure 9). Network Rail told RAIB that the poster
would remain in place until MSLs are installed at the crossing.
102 Network Rail is progressing the implementation of Flex MSLs at Lady Howard
crossing, with a view to completion in February 2024. In the meantime, it has
considered alternative measures, such as convex mirrors or installing SAWDs,
but has considered these to be unsuitable. Convex mirrors could cause glare
or distraction for train drivers, while Network Rail considers that SAWDs are
inappropriate at crossings where whistle boards are not fitted (paragraph 69).
Figure 9: Design of the poster now in place at Lady Howard crossing (courtesy of Network Rail).
Report 01/2023 30 v2 February 2024
Lady Howard crossing
Actions reported as already taken or in progress relevant to
Actions reported as already taken or in progress relevant to this report when it was revised (v2.0)
this report when it was revised (v2.0)
103 In June 2023, Network Rail published a ‘notice board’. This is the method used
to provide guidance on the application of a standard, and the June 2023 notice
board explained the method for applying for a derogation from Network Rail
standard NR/L2/SIG/11201/ModX39, where the likelihood of trains being stopped
at signals within the strike in area is low. This notice board is available to all
signalling designers in the railway industry and is intended to be included in
periodic briefings on standards.
104 A new sign, warning of the possibility of there being an oncoming train hidden
by other trains was designed and included in the Private Crossings (Signs and
Barriers) Regulations 2023.8 This became law on 18 November 2023 (figure 10).
While this law is not directly applicable to public footpath and bridleway crossings,
like Lady Howard, Network Rail has updated its standard NR/L2/ XNG/30020
Module A28 ‘Signage for level crossings’ and its internal guidance to level
crossing managers to require these signs be fitted to such crossings as well.
At the time of publication this sign had been fitted to all footpath level crossings
which have two railway lines or more and do not have any other method of
warning.
Figure 10: Design of sign to diagram 157 in the Private Crossings (Signs and Barriers) regulations 2023
(courtesy of HMSO).
105 Network Rail’s Wessex route applied for and received a derogation from the
standard which has allowed it to fit overlay MSLs at Lady Howard crossing. MSL
equipment was brought into use at the crossing in January 2024 (figure 11).
8
Statutory Instrument 2023 No. 1112 Railways - The Private Crossings (Signs and Barriers) Regulations 2023
https://www.legislation.gov.uk/uksi/2023/1112/made.
Report 01/2023 31 v2 February 2024
Lady Howard crossing
Actions reported as already taken or in progress relevant to this report when it was revised (v2.0)
Figure 11: Lady Howard crossing, fitted with overlay MSLs (courtesy of Network Rail).
Report 01/2023 32 v2 February 2024
Lady Howard crossing
Recommendations and learning point
Recommendations and learning point
Recommendations
106 The following recommendations are made:9
1 The intent of this recommendation is to reduce the risk at footpath and
bridleway level crossings of a second train approaching being hidden
from the view of crossing users by a previously passing train.
Network Rail should:
• use its existing risk assessment data to identify those footpath and
bridleway crossings that present the highest risk to users of a second
train approaching being potentially hidden by another train
• at those crossings identified as presenting the highest risk, implement
appropriate measures to control the risk to users of a second train
approaching
• in deciding what measures to implement, specifically consider
technological solutions, as well as user awareness campaigns. It
should also consider good practice elsewhere in the rail industry
(including internationally) and the predictable limitations of human
performance (paragraphs 90a, 90b and 91).
2 The intent of this recommendation is to ensure that appropriate interim
shorter-term risk mitigations are identified and implemented in a timely
manner at level crossings that are awaiting long-term solutions to reduce
the risk.
Network Rail should review its existing processes for level crossing risk
management and include:
• explicit provision for considering a wider range of short- and medium-
term risk mitigation options than is currently the case
9
Those identified in the recommendations have a general and ongoing obligation to comply with health and safety
legislation, and need to take these recommendations into account in ensuring the safety of their employees and
others.
Additionally, for the purposes of regulation 12(1) of the Railways (Accident Investigation and Reporting) Regulations
2005, these recommendations are addressed to the Office of Rail and Road to enable it to carry out its duties under
regulation 12(2) to:
(a) ensure that recommendations are duly considered and where appropriate acted upon; and
(b) report back to RAIB details of any implementation measures, or the reasons why no implementation measures
are being taken.
Copies of both the regulations and the accompanying guidance notes (paragraphs 200 to 203) can be found on
RAIB’s website www.raib.gov.uk.
Report 01/2023 33 v2 February 2024
Lady Howard crossing
Recommendations and learning point
• steps to ensure that those responsible for implementing risk controls
are aware of all the options available, including those that might
offer only incremental reductions in risk or interim mitigation pending
implementation of preferred long-term solutions
• documented details of short- and medium-term risk controls, including
both technical and non-technical options (paragraph 91).
Learning point
107 RAIB has identified the following important learning point:10
1 Signalling designers and other staff responsible for specifying solutions
are reminded to check whether a derogation from a relevant standard is
possible or whether there are any existing relevant derogations. While
derogations must be used appropriately, particularly where solutions
exist that comply with standards, their use may be justified where they
provide an opportunity to reduce risk in a more timely and cost-effective
manner (paragraph 91).
10
‘Learning points’ are intended to disseminate safety learning that is not covered by a recommendation. They are
included in a report when RAIB wishes to reinforce the importance of compliance with existing safety arrangements
(where RAIB has not identified management issues that justify a recommendation) and the consequences of failing
to do so. They also record good practice and actions already taken by industry bodies that may have a wider
application.
Report 01/2023 34 v2 February 2024
Lady Howard crossing
Appendices
Appendices
Appendix A - Glossary of abbreviations and acronyms
ALCRM All level crossing risk model
FFCCTV Forward-facing closed-circuit television
GSM-R Global system for mobile communications - railway
LCM Level crossing manager
MSL Miniature stop light
NRA Narrative risk assessment
ORR Office of Rail and Road
OTDR On-train data recorder
RLCM Route level crossing manager
SAWD Supplementary audible warning device
Report 01/2023 35 v2 February 2024
Lady Howard crossing
Appendix B - Investigation details
Appendices
RAIB used the following sources of evidence in this investigation:
• information provided by witnesses
• information taken from both trains’ on-train data recorders (OTDRs)
• video footage taken from the FFCCTV of train 1I37 and from a camera at the
crossing
• signalling data
• voice communications
• railway incident control logs
• documentary evidence associated with risk management for Lady Howard and other
crossings on Wessex route
• site photographs and measurements
• weather reports and observations at the site
• a review of previous RAIB investigations that had relevance to this accident.
Report 01/2023 36 v2 February 2024
Lady Howard crossing
This report is published by the Rail Accident Investigation Branch,
Department for Transport.
© Crown copyright 2024
Any enquiries about this publication should be sent to:
RAIB Email: enquiries@raib.gov.uk
The Wharf Telephone: 01332 253300
Stores Road Website: www.gov.uk/raib
Derby UK
DE21 4BA